Incidentalomas in Radiology

AJ Lewis, MD MBA Boca Radiology Group

GRAND ROUNDS 5/23/2017

Disclosures

NONE

Incidental Findings

EVERYWHERE

INCIDENTAL FINDINGS The Latest Management Recommendations

CT or MRI Abdomen/Pelvis:

Adrenal Lesions

Pancreatic Cystic Lesions

Renal Lesions

Liver Lesions, no risk of HCC

Liver Lesions, risk of HCC (LI-RADS)

Splenic Lesions

Lymph Node Findings

Adnexal Lesions Gallbladder and Biliary Lesions

Ultrasound:

Cystic Adnexal Lesions

Other Adnexal Lesions Thyroid Nodules

Chest:

Solid Pulmonary Nodules

Subsolid Pulmonary Nodules *new*

Vascular:

Abdominal Aortic or Iliac Aneurysms

Splenic or Renal Aneuryms

Other Abdominal Vascular Findings

v.5 Sept. 2014

Source: White Paper: Managing Incidental Findings on Abdominal CT, JACR, October 2011

Relevant Links:

Washout Calculator

Caoili et al: CT Characterization of Adrenal Masses, Radiology, 2002

ACR Appropriateness Criteria for Incidental Adrenal Nodule, 2006

Song et al: Prevalence of Adrenal Disease in 1049 Consecutive Adrenal Masses, AJR, 2008

Of 1049 masses, 100% were benign in patients with no suspicion of malignancy.

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Incidental Adrenal Mass

≥ 1 cm

detected on CT or MR

Low attenuation (<10 HU) Right adrenal adenoma

No follow-up needed

Indeterminate right adrenal nodule

Adrenal protocol CT

Incidental Cystic Pancreatic Mass

In an asymtomatic1 patient,

detected on CT, MRI (w/ or w/o

contrast) or US.

Source: White Paper: Managing Incidental Findings on Abdominal CT, JACR, October 2011

Some Relevant Links:

Ip et. al., Focal Cystic Pancreatic Lesions: Variation in Management Recomm., Radiology, April 2011

2.2% of CT’s and 15.9% of MR’s detect focal cystic pancreatic lesions.

Sahani et. al., Pancreatic Cysts 3 cm or Smaller, Radiology, Mar. 2006

87% of cysts <3cm were benign (75 of 86), 97% of unilocular cysts (35 of 36) were benign.

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Indeterminate Cystic Pancreatic Lesion (<2cm)

Follow-up MRI in 1 year

Serous Cystadenoma

>4 cm = resection

Indeterminate Cystic Renal Mass

Bosniak I/II - no followup necessary Bosniak IIF – 6 month followup renal CT or MRI Bosniak III/IV – treated as cancer, require surgery

Management of Incidental Solid Renal Masses:

1. General Population: If less than 1 cm, these masses may

be observed until they are 1 cm or larger (i.e. CT or MR at

3-6 mo then 12 mo). Lesions larger than 1 cm should be

surgically removed, however, hyperattenuating homoge-

neously enhancing masses less than 3 cm may warrant further

characterization with MRI and/or biopsy as these may be

angiomyolipomas with minimal fat.

2. Limited Life Expectancy and Comorbidities: If less than

1 cm, these masses may be observed until they are 1.5 cm or

larger (i.e. CT or MR at 3-6 mo then 12 mo). Lesions 1-3 cm

may be followed or surgically removed, however, hyperat-

tenuating homogeneously enhancing masses less than 3 cm

may warrant further characterization with MRI and/or biopsy

as these may be angiomyolipomas with minimal fat. Lesions

larger than 3 cm may be followed or surgically removed.

Source: White Paper: Managing Incidental

Findings on Abdominal CT, JACR, Oct. 2011

Bosniak Criteria:

Category I: Hairline-thin wall; no septa, calcifications, or solid

components; water attenuation; no enhancement.

Category II: Few hairline-thin septa with or without perceived

(not measurable) enhancement; fine calcification or short segment of slightly thickened calcification in the wall or septa; homogeneously

high-attenuating masses (≤3 cm) that are sharply marginated and do

not enhance.

Category IIF: Multiple hairline-thin septa with or without perceived (not measurable) enhancement, minimal smooth thickening of wall or septa that may show perceived (not measureable) enhancement, calcification may be thick and nodular but no measurable enhancement present; no enhancing soft tissue components; intrarenal nonenhancing high-attenuation renal masses (>3 cm).

Category III: Thickened irregular or smooth walls or septa, with measurable enhancement.

Category IV: Criteria of category III, but also containing enhancing soft tissue components adjacent to or separate from the wall or septa.

Incidental

Cystic Renal Mass detected on CT

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Follow-up in 6 months

Incidental Liver Mass detected on CT

Source: White Paper: Managing Incidental Findings on Abdominal CT, JACR, October 2011

Legend: 1. Low risk individuals: Young patient (≤ 40 years old), with no

known malignancy, hepatic dysfunction, hepatic malignant risk

factors, or symptoms attributable to the liver.

2. Average risk individuals: Patient >40 years old, with no known

malignancy, hepatic dysfunction, abnormal liver function tests or

hepatic malignant risk factors or symptoms attributable to the liver.

3. High risk individuals: Known primary malignancy with a

propensity to metastasize to the liver, cirrhosis, and/or other

hepatic risk factors. Hepatic risk factors include hepatitis, chronic

active hepatitis, sclerosing cholangitis, primary biliary cirrhosis,

hemochromatosis, hemosiderosis, oral contraceptive use, anabolic

steroid use.

4. Follow-up CT or MRI in 6 months. May need more frequent

follow-up in some situations, such as a cirrhotic patient who is a

liver transplant candidate.

5. Benign imaging features: Typical hemangioma (see below),

sharply marginated, homogeneous low attenuation (up to about 20

HU), no enhancement. May have sharp, but irregular margins.

6. Benign low attenuation masses: Cyst, hemangioma, hamartoma,

Von Meyenberg complex (bile duct hamartomas).

7. Suspicious imaging features: Ill-defined margins, enhancement

(more than about 20 HU), heterogeneous, enlargement. To evaluate,

prefer multiphasic MRI.

8. Hemangioma features: Nodular discontinuous peripheral

enhancement with progressive enlargement of enhancing foci on

subsequent phases. Nodule isodense with vessels, not parenchyma.

9. Small robustly enhancing lesion in average risk, young patient:

hemangioma, focal nodular hyperplasia (FNH), transient hepatic

attenuation difference (THAD) flow artifact, and in average risk,

older patient: hemangioma, THAD flow artifact. Other possible

diagnoses: adenoma, arterio-venous malformation (AVM), nodular

regenerative hyperplasia. Differentiation of FNH from adenoma

important especially if larger than 4 cm and subcapsular.

10. Hepatocellular or common metastatic enhancing malignancy:

islet cell, neuroendocrine, carcinoid, renal cell carcinoma, mela-

noma, choriocarcinoma, sarcoma, breast, some pancreatic lesions.

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“Too small to characterize” Lesions

TSTCs in patients without a known malignancy Jones (1992) studied 1500 patients who had an abdominal CT examination: TSTC lesions in 17% of patients In 45 pts without a known malignancy, all lesions were benign In 209 pts with a known malignancy 86 had 1 TSTC: 5% malignant 74 had 2-4 TSTCs: 19% malignant 49 with >5 TSTCs: 76% malignant.

Hypervascular Liver Lesions

Classic Peripheral nodular discontinuous progressive enhancement = hemangioma

Arterial enhancement with central scar that fades to background on delay = FNH

Incidental Adnexal Cystic Mass (≥1 cm) on CT or MRI in Post-Menarchal, Non-Pregnant Females1

1.Exclusions: (a) normal findings, including hypodense ovary, crenulated enhancing wall of corpus luteum, asymmetric ovary

(within 95% confidence interval for size) with normal shape; (b) unimportant findings, including calcifications without associ-

ated noncalcified mass; (c) previous characterization with ultrasound or MRI; and (d) documented stability in size and appear-

ance for >2 years.

2. Cyst: should have all of the following features: (a) oval or round; (b) unilocular, with uniform fluid attenuation or signal

(layering hemorrhage acceptable if premenopausal); (c) regular or imperceptible wall; (d) no solid area, mural nodule; and

(e) <10 cm in maximum diameter.

3.Refers to an adnexal cyst that would otherwise meet the criteria for a benign-appearing cyst except for one or more of the

following specific observations: (a) angulated margins, (b) not round or oval in shape, (c) a portion of the cyst is poorly imaged

(eg, a portion of the cyst may be obscured by metal streak artifact on CT of the pelvis), and (d) the image has reduced signal- to-

noise ratio, usually because of technical parameters or in some cases because the study was performed without intravenous

contrast.

4.Features of masses in this category include (a) solid component, (b) mural nodule, (c) septations, (d) higher than fluid attenu-

ation, and (e) layering hemorrhage if postmenopausal.

5. This indicates that ultrasound should be performed promptly for further evaluation, rather than in follow-up.

6.A benign-appearing cyst >5 cm with suspected internal hemorrhage in a patient aged >55 years, or within 5 years of meno-

pause, should be followed in 6 to 12 weeks because hemorrhagic cysts in early postmenopause are possible, although rare.

7. May decrease threshold from 3 cm to lower values down to 1 cm to increase sensitivity for neoplasm.

Source: White Paper: Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 1: Adnexal Findings, JACR Sept. 2013

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Source: Levine et. al. Management of Asymptomatic Ovarian and Other Adnexal Cysts Imaged at US,

Society of Radiologists in Ultrasound Consensus Statement, Ultrasound Quarterly 2010;26:121-131.

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Source: Levine et. al. Management of Asymptomatic Ovarian and Other Adnexal Cysts Imaged at US,

Society of Radiologists in Ultrasound Consensus Statement, Ultrasound Quarterly 2010;26:121-131.

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Management of Thyroid Nodules detected by ultrasound.

Note: Use largest measurement for size. FNA is likely unnecessary in a diffusely enlarged gland with multiple

nodules of similar US appearance without intervening normal parenchyma. Presence of abnormal lymph nodes

overrides US features of thyroid nodule(s) and should prompt US-guided FNA or biopsy of lymph node and/or

ipsilateral nodule.

Note: Combining these factors improves the positive predictive value of US. For example, a predominantly

solid nodule with microcalcifications has a 31.6% likelihood of being cancer, as compared to a

predominantly cystic nodule with no calcification, which has a 1.0% likelihood of being cancer.

Source: Frates et. al. Management of Thyroid Nodules Detected at Ultrasound, SRU Consensus Confer-

ence Statement. Radiology 2005;237:794-800 and Ultrasound Quarterly 2006;22:231-240.

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Ultrasound Feature Recommendation

Microcalcifications Strongly consider US-guided FNA if ≥ 1.0 cm

Solid (or almost entirely solid) and/or

coarse calcifications.

Strongly consider US-guided FNA if ≥ 1.5 cm

Mixed solid and cystic, or almost

entirely cystic with solid mural

component.

Consider US-guided FNA if ≥ 2.0 cm

Substantial growth since prior US

exam.

Consider US-guided FNA

Almost entirely cystic and none of

the above and no substantial growth

(or no prior US)

US-guided FNA probably unnecessary

Multiple nodules Consider US-guided FNA of one or more

nodules, with selection prioritized on basis of

criteria (in order listed) for solitary nodule

Ultrasound Features

Associated with

Thyroid Cancer

Sensitivity (%) Specificity (%) Positive

Predictive Value

(%)

Negative

Predictive Value

(%)

Microcalcifications 26 - 59 86 - 95 24 - 71 42 - 94

Hypoechoic 27 - 87 43 - 94 11 - 68 74 - 94

Irregular margins or

no halo

17 - 78 39 - 85 9 - 60 39 - 98

Solid 69 - 75 53 - 56 16 - 27 88 - 92

Intranodule vascularity 54 - 74 79 - 81 24 - 42 86 - 97

More tall than wide 33 93 67 75

Thyroid Microcalcifications

Management of Pulmonary Nodules newly detected incidentally at nonscreening CT in persons 35 or older.

† Low risk is defined as:

Minimal or absent history of smoking or other known risk factors.

‡ High risk is defined as one or more of the following:

• ≥ 20 pack-year history of smoking, or equivalent second-hand exposure.

• Personal history of cancer or family history of lung cancer.

• Occupational exposure (asbestos, beryllium, silica, uranium, radon).

• Chronic interstitial/fibrotic lung disease.

§ Low risk patient with ≤ 4 mm nodule:

The risk of malignancy in this category (1%) is substantially less than that in a baseline CT scan of an

asymptomatic smoker.

Young Patients: Primary lung cancer is rare in persons under 35 years of age (1% of all cases), and the risks from

radiation exposure are greater than in the older population. Therefore, unless there is a known primary cancer,

multiple follow-up CT studies for small incidentally detected nodules should be avoided in young pa- tients. In

such cases, a single low-dose follow-up CT scan in 6–12 months should be considered.

Caution:

1.Fever: In certain clinical settings, such as a patient presenting with neutropenic fever, the presence of a nodule

may indicate active infection, and short-term imaging follow-up or intervention may be appropriate.

2. Cancer: Guidelines may not apply for individuals with known or suspected malignant disease.

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home Subsolid Pulmonary Nodules Fleischner Society Recommendations for Subsolid Nodules Found on CT

The development of a standardized approach to the interpretation and management of subsolid nodules remains critically important

given that peripheral adenocarcinomas represent the most common type of lung cancer, with evidence of increasing frequency.

Note: These guidelines assume meticulous evaluation, optimally with contiguous thin sections (1 mm) recon-

structed with narrow and/or mediastinal windows to evaluate the solid component and wide and/or lung

windows to evaluate the nonsolid component of nodules, if indicated. When electronic calipers are used,

bidimensional measurements of both the solid and ground-glass components of lesions should be obtained as

necessary. With serial scans, always compare with the original baseline study to detect subtle indolent growth.

The use of a consistent low-dose technique is recommended, especially in cases for which prolonged follow-up

is recommended, particularly in younger patients. See example:

Source: Naidich et al. Recommendations for the Management of Subsolid Pulmonary Nodules Detected

at CT: A Statement from the Fleischner Society. Radiology, January 2013.

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Abdominal Aortic Aneurysms And ectatic abdominal aortas - recommended intervals for initial follow-up imaging

Note: An abdominal aorta ≥ 1.5 times the normal diameter or ≥ 3.0 cm or is defined as aneurysmal. For abdomi-

nal aortic diameters < 2.5 cm, follow-up is generally thought to be unnecessary. Because the rupture of smaller

abdominal aortic aneurysms is less likely, we recommend longer intervals between follow-up examinations.

Follow-up intervals may vary depending on comorbidities and the growth rate of the aneurysm.

Iliac Artery Aneurysms Recommended intervals for initial follow-up imaging of common/internal/external iliac artery aneurysms

*The white paper says, “Aneurysms that are < 3.0 cm in diameter tend to be asymptomatic, rarely rupture, and

expand slowly” and no recommendation is made. Simply describe the finding.

Note: Iliac artery aneurysm is defined as a diameter > 1.5 times normal, or ≥ 2.5 cm in diameter.

Penetrating Aortic Ulcers Recommendations for follow-up imaging in asymptomatic patients

Annual follow-up is recommended when asymptomatic,

and more frequently if symptoms arise, with consideration of surgical/endovascular intervention.

Note: Lack of symptoms does not necessarily imply stability. Studies have shown that the natural history of

penetrating aortic ulcers (PAU) is variable and unpredictable. A PAU (which represents disruption of atheroscle-

rotic plaque with penetration of luminal blood for variable distances into or through the aortic wall) may prog-

ress to an intramural hematoma, focal dissection, or pseudoaneurysm/rupture, or it may completely resolve.

Source: White Paper: Managing Incidental Findings on Abdominal/Pelvic CT and MRI, Part 2: Vascular

Findings, JACR, October 2013

Aortic Diameter (cm) Imaging Interval

2.5 - 2.9 cm 5 years (defined as ectatic)

3.0 - 3.4 cm 3 years

3.5 - 3.9 cm 2 years

4.0 - 4.4 cm 1 year

4.5 - 4.9 cm 6 months - also consider surgical or

endovascular referral.

5.0 - 5.5 cm 3-6 months - also consider surgical or

endovascular referral.

Aneurysm Diameter (cm) Imaging Interval

< 3.0 cm No explicit recommendation is made*

3.0 - 3.5 cm 6-month follow-up cross-sectional imaging

> 3.5 cm Close follow-up or expeditious treatment

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Splenic Artery Aneurysms Recommended intervals for initial follow-up imaging

*Clinical risk factors for rupture should be carefully assessed (such as attributable symptoms, a woman of child-

bearing years, and cirrhosis, especially when associated with alpha-1 antitrypsin deficiency).

Note: Aneurysms showing rapid increase in size should be treated. Surveillance intervals greater than 1 year

may be reasonable in patients with comorbidities and/or limited life expectancy.

Renal Artery Aneurysms Recommended intervals for initial follow-up imaging

Note: Consider the alternate diagnosis of a pseudoaneurym due to trauma. Evaluate for evidence of

fibromuscu- lar dysplasia, particularly in younger women. The decision to treat a renal artery aneurysm should

be based on factors including patient age, gender, presence of hypertension, and aneurysm location and size.

Vascular recommendations continued on next page...

Source: White Paper: Managing Incidental Findings on Abdominal/Pelvic CT and MRI, Part 2: Vascular

Aneurysm Diameter (cm) Imaging Interval

< 2.0 cm Yearly follow-up is recommended*

≥ 2.0 cm Consider endovascular treatment

Aneurysm Diameter (cm) Imaging Interval

1.0 - 1.5 cm 1-2 year follow-up imaging

> 1.5 to 2.0 cm Consider surgical or endovascular treatment

Source: White Paper: Managing Incidental Findings on Abdominal/Pelvic CT and MRI, Part 2: Vascular

Findings, JACR, October 2013

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Other Abdominal Vascular Findings

Pancreaticoduodenal aneurysms are felt to be at higher risk for rupture, and some authors recommend

that all of these aneurysms undergo surgical or endovascular treatment regardless of size. If a decision is made

to observe rather than treat, repeat scanning at annual intervals is recommended.

Treatment is generally recommended for aneurysms >2 cm in diameter, possibly with a smaller threshold

for nonatherosclerotic aneurysms. For hepatic aneurysms, Abbas et al established that multiplicity and nonath-

erosclerotic origin were linked to increased rupture rate.

Researchers have found that isolated visceral arterial dissections (typically the SMA) can be followed

rather than treated promptly when asymptomatic.

Atherosclerotic stenosis commonly affects the celiac, SMA, and IMA. As long as this remains well com-

pensated by collateral vessels and is not symptomatic with postprandial abdominal pain or weight loss, no

further evaluation or follow-up is recommended.

The prevalence of abominal venous thrombosis on CT was 1.74% in a series of 2619 patients. How to

further evaluate venous thrombosis depends on location and the local availability and expertise for particular

techniques.

Although incompetence of the ovarian and draining pelvic veins (and resultant venous reflux) are considered

the main cause of pelvic congestion syndrome, dilated pelvic veins are often seen incidentally in asymp-

tomatic multiparous women. No further imaging or intervention is recommended in asymptomatic women with

incidentally discovered dilated pelvic veins.

Both cadaveric and retrospective CT studies from asymptomatic patients suggest that compression of the left

common iliac vein by the anteriorly crossing right common iliac artery (an anatomic variant known as May-

Thurner or iliocaval compression syndrome) is present in approximately 25% of the population,

indicating that most patients with compression are not symptomatic, and follow-up is not necessary unless the

patient develops unilateral symptoms of leg swelling or thrombosis. Similarly, compression of the left renal vein

between the aorta and superior mesenteric artery with localized varices, known as nutcracker syndrome, is

an occasional asymptomatic incidental finding.

* Benign Features: normal short-axis diameter (<1cm in retroperitoneum), normal architecture (elongated,

fatty hilum), normal enhancement, normal node number.

† Suspicious Features: enlarged short-axis diameter (≥1 cm in retroperitoneum), architectural distortion

(round, indistinct hilum), enhancement (necrosis/hypervascular), increased number (cluster of ≥3 lymph nodes

in a single nodal station or cluster of ≥2 lymph nodes in ≥2 regions).

‡ Non-neoplastic Disease: e.g. infection, inflammation, connective tissue disorders.

§ Other Evaluation: PET/CT, MIBG, endoscopic ultrasound.

Source: White Paper: Managing Incidental Findings on Abdominal/Pelvic CT/MRI, Part 3: Splenic and

Nodal Findings, JACR, November 2013

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Incidental Lymph Node Findings on CT or MRI

Suspicious Retroperitoneal Node

Testicular Cancer Metastasis

*Cyst: imperceptible wall, near-water attenuation (<10 HU), no enhancement.

*Hemangioma: discontinuous, peripheral, progressively centripetal enhancement (these findings are less com-

mon in the spleen compared to the liver).

‡ Benign features: homogeneous low attenuation (<20 HU), no enhancement, smooth margins.

¶ Indeterminate features: heterogeneous, intermediate attenuation (>20 HU), enhancement, smooth margins.

|| Suspicious features: heterogeneous, enhancement, irregular margins, necrosis, splenic parenchymal or

vascular invasion, substantial enlargement.

# Follow-up: MRI in 6-12 months.

§ Evaluate: PET vs. MRI vs. biopsy.

Source: White Paper: Managing Incidental Findings on Abdominal/Pelvic CT/MRI, Part 3: Splenic and

Nodal Findings, JACR, November 2013

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Incidental Splenic Lesion on CT or MRI

Suspicious Splenic Lesions

GI primary with metastases to spleen

Pituitary Adenoma

Endocrine Society practice guidelines recommend: - Macroadenoma – f/u MRI at 6 months, then

“progressively less frequently” if stable - Microadenoma – f/u MRI at 1 year, then

“progressively less frequently” if stable

Meningioma

British Medical Society practice guidelines recommend: - Follow-up yearly with contrast enhanced MRI for

all meningiomas

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Incidental Gallbladder and Bile Duct Findings Summary of Diagnosis and Management in Asymptomatic Patients evaluated by CT or MRI

Notes: 1.Porcelain Gallbladder: Large retrospective studies have shown that the prevalence of malignancy in resected porcelain

gallbladders is 5-7% compared to 0.6 - 0.8% in the general population. Incidence of new cancer in a porcelain gallblad- der

is likely to be < 1% per year (inferred from available data); only a small fraction of this would likely be detected and treated

differently if yearly follow-up were done. Therefore, the committee generally does not recommend follow-up.

2.Diffuse gallbladder wall thickening: In the absence of one of the above-mentioned secondary causes, a primary cause

should be excluded by clinical history. If the thickening is uniform or nearly so, the risk for an underlying malignancy is

negligible.

3.Polyps: Evidence for their management is inconclusive and based on ultrasound; the authors infer that this data is also

applicable to CT and MRI. One study of 346 patients with gallbladder polyps found no malignancies and only one polyp

7-9 mm in size and two polyps > 10mm. Another study of 467 patients found that only 6.6% of polyps grew, and 3.7%

were malignant or had malignant potential, including benign adenomatous and dysplastic potential. Only 0.7% were

frankly malignant. The authors recommended follow-up for polyps 5-10 mm in size.

4.Biliary duct dilatation: Defined as > 6 mm in a patient < 60 years of age with the gallbladder present, or a common bile

duct > 10 mm with the gallbladder absent. Because biliary dilatation is often chronic and asymptomatic, liver function tests

(alkaline phosphatase, bilirubin) can help assess the importance of this finding. If there is suspicion of a biliary tract mass,

MRCP may be performed. However, if the suspected mass is in the lower third of the common bile duct, endoscopic

ultrasound (EUS) or ERCP-guided FNA may be preferred as the first option.

Source: White Paper: Managing Incidental Findings on Abdominal/Pelvic CT and MRI, Part 4:

Gallbladder and Biliary Findings, JACR, December 2013

Finding Finding/Diagnosis Action

Gallstones, no mass Gallstones If symptomatic, ultrasound

Gallbladder wall calcification,

no mass

Focal or diffuse (porcelain gallbladder) No follow-up recommended; if followed, use post-

contrast CT

Dense gallbladder contents

(20-100 HU)

Sludge, excreted contrast, hemorrhage,

gallstones

No evaluation or follow-up recommended specifically

for this finding

Diffuse gallbladder wall

thickening > 3mm, no mass

Hepatitis, CHF, liver disease, pancreatitis,

hypoproteinemia

No evaluation or follow-up recommended specifically

for this finding

Focal gallbladder wall

thickening or mass

Polyp, gallbladder cancer, cholesterolosis,

adenomyomatosis, xanthogranulomatous

cholecystitis

Evaluation and follow-up depends on mass size, other

clinical factors; ultrasound may show specific features

for adenomyomatosis (i.e. “comet-tail” artifact)

Gallbladder polyp ≤ 6 mm Benign polyp No evaluation or follow-up recommended

Gallbladder polyp 7-9 mm Benign polyp, adenoma, or small cancer Follow yearly with ultrasound; surgical consult if polyp

grows

Gallbladder polyp ≥ 10 mm,

mass

Benign polyp, adenoma, or small cancer Surgical consult

Pericholecystic fluid Gallbladder perforation, other collection Individual assessment

Distended gallbladder ( > 4cm

transverse, > 9cm long)

Fasting, obstruction If asymptomatic, no evaluation

Ductal dilation > 6 mm, or

> 10 mm if gallbladder absent

Obstruction, post-cholecystectomy If lab results normal, no evaluation; if abnormal, ERCP,

EUS, or MRCP as appropriate.

Incidental Gallbladder Polyp

8 mm – follow-up ultrasound when ???

Recap

Thank You!! Thank You!!

Management of Adnexal Lesions newly detected incidentally on US in asymptomatic* nonpregnant females.

* These recommendations may be helpful in symptomatic women as well, but the clinical setting will often deter-

mine management in a manner beyond the scope of these recommendations.

† Size: Use the maximum diameter.

•Simple Cyst: A simple cyst is round or oval, anechoic, smooth thin walls, posterior acoustic enhancement, no

solid component or septation, and no internal flow. The entire cyst must be visualized. Assess all cysts with color/

power Dopper. The rare cyst that turns out to be malignant is usually large (> 7 cm) and the cyst wall was presum-

ably incompletely imaged, with a missed small mural nodule. Over 99% of simple cysts up to 10cm in a patient of

any age are benign, either non-neoplastic (physiologic, paraovarian, or paratubal) or benign neoplastic cysts (in-

cluding serous and mucinous cystadenomas).

Follow-up recommendations for a hemorrhagic cyst, endometrioma, dermoid, indeterminate lesion, and other

lesions, as well as simple cysts, are presented with example images in the tables on the following three pages.

Length of follow-up: No consensus was reached regarding how long a lesion must be followed to demonstrate its

stability. Cystic ovarian neoplasms generally grow very slowly.

Source: Levine et. al. Management of Asymptomatic Ovarian and Other Adnexal Cysts Imaged at US,

Society of Radiologists in Ultrasound Consensus Statement, Ultrasound Quarterly 2010;26:121-131.

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Cyst Size Reproductive Age Female

≤ 3 cm † No follow-up. Normal physiology. At your

discretion, may not need to be described in

the report.

> 3 to 5 cm No follow-up. Describe in report and

include “almost certainly benign”.

> 5 to 7 cm Yearly follow-up. Describe in report and

include “almost certainly benign”.

> 7 cm Further evaluation with MR or surgery

should be considered since these may be

difficult to assess completely with US.

Cyst Size Postmenopausal Female †

≤ 1 cm No follow-up. Clinically inconsequential.

At your discretion, may not need to be

described in the report.

> 1 to 7 cm Describe and include “almost certainly

benign” and recommend yearly follow-up,

at least initially, with US.

> 7 cm Further imaging with MR or surgery.